Provider Demographics
NPI:1740287259
Name:BRIDDELL, DERRICK ANTONIO (PT, DSC, MS, SCS)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:ANTONIO
Last Name:BRIDDELL
Suffix:
Gender:M
Credentials:PT, DSC, MS, SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-0054
Mailing Address - Country:US
Mailing Address - Phone:252-367-1118
Mailing Address - Fax:800-505-8690
Practice Address - Street 1:1496 STILL MEADOW BLVD STE DANDE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-7511
Practice Address - Country:US
Practice Address - Phone:443-365-2729
Practice Address - Fax:443-365-2730
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110982251S0007X, 2251S0007X
NCP110982251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212305Medicaid